VBS Form

VBS Registration Form

Please fill out the form below for submission of your child's participation. This year, VBS will be onsite at the East Lake Community Center. Address of the center is shown below. If you have any questions or concerns, please contact us at (423) 698-8086.
Monday, June 16th - 19th 5:30-7:30pm

Location will be at the East Lake Community Center - 3601 Dodds Ave., Chattanooga, TN 37407

Child Participant Information
Participant Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Grade
Medical Problems/ Allergies / Special Needs*

Parent's Contact Information
Parent / Guardian's Name*

First NameLast Name
Phone Number (Daytime / Emergency)*
Phone Number (Evening)
E-mail*
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Do you currently have a home church?

YesNo
If Yes, where?
Tell us how you learned about VBS at Resurrected Baptist Church:

RBC WebsiteInternetNewspaperFlyer / PosterRBC MemberInvited by a friend

Liability Information
CONSENT FOR MEDICAL TREATMENT | As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

Signature
By signing and submitting this registraiton form, you understand and agree to all policies.
Parent/Guardian Signature*

First NameLast Name
Today's Date*

MonthDayYear
Date
Comments and/or Questions:
Should be Empty: